MEDICAL CENTER OF THE ROCKIES | POUDRE VALLEY HOSPITAL

BACKGROUND • Sepsis is a medical term to describe the body’s systemic and detrimental

response to a known or suspected infection.

• If sepsis is not identified and treated early in the infectious process it can progress to severe sepsis (one organ system failure), septic shock (multiple organ failure), and death.

• Sepsis contributes to over 500,000 emergency room (ED) visits in the U.S. annually with associated costs over $20 billion.

• Over 80% of adult inpatients with sepsis are admitted through the ED.

• Patients with severe sepsis or septic shock consistently have higher hospital mortality rates resulting from delayed provider recognition and lack of standardized treatment interventions.

• Sepsis continues to be a primary cause of infection related deaths in the U.S. with mortality rates up to 50%.

• Sepsis is one of the most expensive diseases treated in the U.S. compared to all other hospitalizations ($103,529 vs. $17,298).

• Severe sepsis and septic shock mortality and associated length of stay (LOS) may be reduced when bundled care treatments are implemented.

OBJECTIVE• Reduce adult inpatient sepsis mortality and associated length of stay (LOS) by

implementing standardized processes for early recognition and treatment of severe sepsis and septic shock in the ED.

• Primary Outcome- Reduce adult inpatient severe sepsis and septic shock mortality by 25% (12%

to 9%).

• Secondary Outcome- Reduce hospital LOS by 10% (6.5 days to 5 days).

• Achieve outcomes in a 12 month period: January to December, 2014

INTERVENTION• In two non-profit community based Magnet hospitals three root causes of sepsis

mortality were identified:- Provider and staff sepsis knowledge base

- Delayed recognition of signs and symptoms of sepsis, severe sepsis, and septic shock

- Lack of standardized sepsis treatment interventions

• Quality Improvement Interventions:- Provider and staff sepsis education using computer-based training and high-

fidelity simulation

- Implement sepsis screening at ED triage

- Implement sepsis alert and treatment algorithms

- Implement electronic ED sepsis order set (includes Surviving Sepsis Campaign Guidelines 3 and 6 hour bundle treatment interventions)

- Revise ED RN collaborative practice orders

METHODS • Pre-post intervention QIP study design

- Pre-intervention: October – December, 2013

- Post-intervention: October – December, 2014

• Data Sources - University Health System Consortium database

- Electronic health records

• Inclusion- Adult patients ≥ 18 years old admitted to an adult inpatient unit

- Primary or secondary discharge diagnosis of sepsis, severe sepsis, or septic shock

• Analysis- Retrospective data collected monthly

- Fisher’s Exact test was used to analyze categorical variables

- Two-tailed independent t-test was used to compare continuous variables

• Quality measures:- Adult inpatient sepsis mortality

- Adult inpatient sepsis LOS

• Process measures:- Serum lactate within three hours of sepsis detection

- Blood cultures drawn prior to antibiotic administration

- Antibiotics administered within one hour of sepsis detection

- Appropriate fluid resuscitation (30 ml/kg) initiated

- Utilization of the electronic ED sepsis order set

RESULTS/OUTCOMES• 650 encounters included

- Pre-intervention group (n=223): 44% female, 56% male.

- Post-intervention group (n=427): 45% female, 55% male.

• Reduced adult inpatient severe sepsis and septic shock mortality by 33% (OR = 1.51, z = 1.48, p < 0.139; 95% CI [0.87, 2.61])

• Decreased adult inpatient sepsis LOS from 6.5 (M = 6.25, SD = 4.76) to 5.23 days (M = 5.23, SD = 4.63); t (648) = 2.32, p =0.021

CONCLUSIONS

• UC Health Northern Region’s sepsis initiative has been successful and continues to evolve.

• Appropriate and timely sepsis screening in the ED improves early recognition and appropriate treatment of the sepsis patient; reducing sepsis mortality and length of stay.

• Improved adherence to treatment algorithms and bundled interventions in the ED was found to be essential to consistently improve patient outcomes.

REFERENCES• Buck, K. M. (2014). Developing an early sepsis alert program. Journal of Nursing Care Quality, 29(2), 124-132.

• Cannon, C. M., Holthaus, C. V., Zubrow, M. T., Posa, P., Gunaga, S., Kella, V., ... Rivers, E. P. (2013). The GENESIS project (GENeralized early sepsis intervention strategies): A multicenter quality improvement collaborative. Journal of Intensive Care Medicine, 28(6), 355-368.

• Chalupka, A. N., & Talmor, D. (2012). The economics of sepsis. Critical Care Clinics, 28(1), 57-76. doi:10.1016/j.ccc.2011.09.003

• Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., ... The Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165-228.

• Dumont, L., Harding, A.D. (2013). Development and implementation of a sepsis program. Journal of Emergency Nursing, 39(6), 625-630.

• Rivers, E. P., Rubinfeld, I. S., Manteuffel, J., Dagher, G. A., McGregor, K., & Mlynarek, M. (2011). Implementing sepsis quality initiatives in a multiprofessional care model. ICU Director, 2(5), 147-157.

• Torio, C. M., & Andrews, R. M. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. (2013). National inpatient hospital costs: the most expensive conditions by payer, 2011 (Brief # 160)

• Wang, H. E., Devereaux, R. S., Yealy, D. M., Safford, M. M., & Howard, G. (2009; 2010).National variation in states sepsis mortality: A descriptive study. International Journal of Health Geographics, 9(1), 9. doi:10.1186/1476-072X-9-9

Reducing Inpatient Adult Severe Sepsis and Septic Shock Mortality: A Quality Improvement ProjectCheryl Milner, DNP, RN, ACNS-BC, CCRN | Rebecca Kubala, BSN, RN | Kerry Borrego, BSN, BS, RN, CEN

UC HEALTH NORTHERN REGION ADULT INPATIENT SEPSIS LOS OCTOBER 2013 - DECEMBER 2014

UC HEALTH NORTHERN REGION ADULT INPATIENT SEPSIS MORTALITY OCTOBER 2013 - DECEMBER 2014

SERUM LACTATE WITHIN 3 HOURS OF SEPSIS DETECTION JANUARY - DECEMBER 2014

ANTIBIOTICS IN ONE HOUR OF SEPSIS DETECTION JANUARY - DECEMBER 2014

FLUID BOLUS RESUSCITATION 30 ML/KG JANUARY - DECEMBER 2014

QIP TIMELINE

• Overall compliance with process measures showed small improvement; 47% to 50%

• Reduced sepsis related ICU bed utilization from 43% to 22%

• Reduced sepsis related mean observed cost of care by 23%

ED SEPSIS ORDER SET IMPLEMENTED JANUARY - DECEMBER 2014

BLOOD CULTURES PRIOR TO ANTIBIOTICS JANUARY - DECEMBER 2014

Post

Intervention

Pre

Intervention